Nicholas Mays

Interregional variations in measures of health from the Health and Lifestyle Survey and their relation with indicators of health care need in England.

STUDY OBJECTIVE--The aim was to assess the extent to which a range of routinely available need indicators which have been suggested for use in NHS spatial resource allocation formulas were associated geographically in England with the different dimensions of population health status collected in the 1985/86 Health and Lifestyle Survey (HLS). DESIGN--Regional health authorities were ranked according to each of the HLS health variables which varied significantly between authorities. The HLS health variables were regressed on a selection from the range of routinely available morbidity and socioeconomic indicators available from the 1981 census. The potential need indicators were also regressed on the health variables. SETTING--The analyses were undertaken at individual level and at regional health authority level in England. SUBJECTS--The study comprised the English component of the HLS random sample representative of the population in private households in Great Britain. MAIN RESULTS--The different HLS health variables did not yield consistent regional health authority rankings. Among the variables, forced expiratory volume in one second (FEV1) and self assessed health appeared to be associated with most of the other health and need variables except longstanding illness. Longstanding illness was not strongly associated with any of the other HLS health variables but appeared to show some association with three deprivation indices constructed from the 1981 Census. CONCLUSIONS--There may be a case for including a measure of chronic ill health in the new NHS system of capitated finance in addition to the all cause standardised mortality ratio which is used currently as a measure of need for health care.

Relation between all cause standardised mortality ratios and two indices of deprivation at regional and district level in England.

The use of mortality data in the form of standardised mortality ratios (SMRs) to measure the need for health care resources in the Resource Allocation Working Party (RAWP) formula in England has been criticised for underestimating the wider effects of adverse socioeconomic conditions on need, particularly in inner city areas. To assess this criticism, we explored the relationships at NHS Regional and District levels in England between two indicators of illness from the 1981 Census, two contrasting indices of deprivation based on the 1981 Census (the Jarman 8 Underprivileged Area (UPA) score and Townsends Index of Material Deprivation) and their constituent variables, and all cause SMRs for 1982-3. All cause SMRs were highly correlated at Regional and District level with permanent and temporary sickness rates. At Regional level, three of the Thames Regions showed relatively high deprivation scores in relation to their SMRs, in comparison to the remaining Regions where the relative level of deprivation closely matched the Regions mortality ranking. District level analyses of the relations between SMRs and the deprivation indices and their constituent variables showed that the Thames/non-Thames dichotomy was accounted for by the 14 Districts in inner London. These findings suggest that although there may be a prima facie case for including an allowance for deprivation in RAWP, it is still not clear how the deprivation variables available in the Census relate empirically to the need for additional health service resources. The analysis raises questions about the appropriate definition of need in this context and whether the Census is a suitable source for the construction of a deprivation weighting for use in national RAWP.

Patients, Policies and Politics: Before and After Working for Patients

clinically normal legs in a study using duplex sonography.5 When we choose a cut off point between normal and abnormal, do we really measure a disease or a physiological variant? Sensitive methods, such as duplex sonography, are undoubtedly valuable but the practical implications of finding subclinical cases in a population must be studied further. In addition, even duplex sonography cannot assess the aesthetic and symptomatic dimensions of varicose disease. We look forward to seeing the results of the Edinburgh Vein Study.

Book Reviews : Quality and Regulation in Health Care: international experiences Robert Dingwall and Paul Fenn, eds. Routledge, London and New York, 1992, vii + 157pp, £35

In the final chapter Sullivan speculates about the future of welfare in the 1990s. Writing shortly after the 1992 election Sullivan suggests that in Britain the Conservatives will continue to give low priority to welfare spending and that the Labour party will continue to adapt to ’new times’ rather than attempt to promote an alternative welfare strategy based on collectivism. In the case of Sweden, Sullivan tends to the view that current welfare reforms are best viewed as pragmatic adjustments to changing domestic and international circumstances. Although this has been the case in the past it is possible that we may be witnessing a much more significant movement away from universalism which might gather pace not only as a result of wider economic and political forces but also because of generational factors (the commitment of those under 35 to welfarism appears to be of a more contingent kind). Finally, Sullivan’s prediction that the election of Clinton in the USA is unlikely to herald a dramatic shift in welfare